Cough is an explosive expiratory maneuver that is reflexively or deliberately intended to clear the airways.

Coughing is a normal

response to the presence of mucus or other foreign material in the airway or upper airway, but persistent coughing is annoying and

generally indicates irritation of the pulmonary airways. It is the 5th most common symptom prompting patients to visit their physician.

Awareness of cough varies considerably. A cough that appears suddenly, interferes with sleep, or causes musculoskeletal chest wall

pain can be distressing. A cough that develops over decades (eg, in a smoker with mild chronic bronchitis) may be hardly noticeable

or may be considered normal by the patient.

Etiology
Likely etiologies of cough differ depending on whether the symptom is acute (< 3 wk) or chronic.

Acute cough is most often caused by a URI, especially the common cold. Other causes include pneumonia; postnasal drip resulting

from rhinitis or sinusitis that can be allergic, viral, or bacterial in origin; and COPD exacerbations. Cough may rarely be the only

presenting symptom of pulmonary embolus. In the elderly, acute cough may signify aspiration or heart failure.

Chronic cough in smokers is most often caused by chronic bronchitis, defined as the presence of productive cough over 3 mo for >

2 yr consecutively. Compression of upper airways by tumor is much less common but should always be considered. The most

common causes regardless of smoking history include postnasal drip syndrome, gastroesophageal reflux disease (GERD), asthma

(cough-variant asthma), and use of ACE inhibitors. Less common causes include eosinophilic bronchitis (characterized by sputum

eosinophilia without airway hyperresponsiveness) and bronchiectasis. The causes of chronic cough in children are similar to those of

adults, but aspiration and pertussis must also be considered. Tracheobronchitis after a URI is a common cause of cough but rarely

lasts > 3 mo after the infection. Rarely, impacted cerumen or a foreign body in the external auditory canal triggers reflex cough

through stimulation of the auricular branch of the vagus nerve. Psychogenic cough is even rarer and is a diagnosis of exclusion.

Evaluation
History: URI and sinus symptoms suggest postnasal drip syndrome, but postnasal drip often causes cough without other symptoms.

Heartburn, hoarseness, and chronic nocturnal or early morning cough, especially if no other symptoms are present, suggests GERD.

Cough after exposure to dusts or allergens suggests cough-variant asthma. Chronic cough with production of purulent sputum in

smokers suggests chronic bronchitis. A change in cough in these patients may, however, be an early manifestation of lung cancer.

Cough productive of gritty sputum may signify broncholithiasis. Copious volumes of sputum suggest alveolar cell carcinoma.

Physical examination: Physical examination should focus on signs of sinusitis, rhinitis, and postnasal drip. Lung auscultation during

cough may help detect lung sounds suggestive of asthma (wheezing) or bronchiectasis (rhonchi). Examination of the ears can detect

triggers of reflex cough.

Testing: Most patients with acute or chronic cough without clear etiology by history and examination can be treated empirically for

postnasal drip syndrome, GERD, or asthma based on clinical judgment; an adequate response to these therapeutic interventions

precludes the need for further testing. A chest x-ray can be performed but usually is not helpful. Patients with chronic cough and

inadequate responses to interventions can undergo more extensive testing for asthma (pulmonary function tests with methacholine

challenge, sinus disease [sinus CT], or GERD [esophageal pH monitoring]). Bronchoscopy should be performed in selected patients

in whom lung cancer or other bronchial tumor is suspected.

Treatment
Treatment is management of the underlying cause. Little evidence exists to support the use of cough suppressants or mucolytic

agents for cough, but patients often expect or request such treatment, and multiple options exist. Coughing is an important

mechanism for clearing secretions from the airways and can assist in treating respiratory infections. Therefore, cough suppression in

infectious conditions should be done with caution. Nonspecific treatments for cough should be reserved as much as possible for

patients with a URI and for those receiving therapy for the underlying cause but for whom cough is still troubling.

Antitussives depress the medullary cough center ( dextromethorphan SOME TRADE NAMES

BENYLIN DM

DELSYM

DEXALONE

Click for Drug Monograph

and codeine SOME TRADE NAMES

NO US TRADE NAME

Click for Drug Monograph

) or anesthetize stretch receptors of vagal afferent fibers in bronchi and alveoli ( benzonatate SOME TRADE NAMES

TESSALON

Click for Drug Monograph

). Dextromethorphan SOME TRADE NAMES

BENYLIN DM

DELSYM

DEXALONE

Click for Drug Monograph

, a congener of the narcotic levorphanol SOME TRADE NAMES

LEVO-DROMORAN

Click for Drug Monograph

, is effective as a tablet or syrup at a dose of 15 to 30 mg 1 to 4 times/day for adults or 0.25 mg/kg qid for children. Codeine SOME

TRADE NAMES

NO US TRADE NAME

Click for Drug Monograph

has antitussive, analgesic, and sedative effects, but dependence is a potential problem, and nausea, vomiting, constipation, and

tolerance are common adverse effects. Usual doses are 10 to 20 mg po q 4 to 6 h as needed for adults and 0.25 to 0.5 mg/kg qid for

children. Other opioids (eg, hydrocodone, hydromorphone SOME TRADE NAMES

DILAUDID

Click for Drug Monograph

, methadone SOME TRADE NAMES

DOLOPHINE

Click for Drug Monograph

, morphine SOME TRADE NAMES

DURAMORPH

MS CONTIN

MSIR
ROXANOL

Click for Drug Monograph

) have antitussive properties but are avoided because of high potential for dependence and abuse. Benzonatate SOME TRADE

NAMES

TESSALON

Click for Drug Monograph

, a congener of tetracaine SOME TRADE NAMES

PONTOCAINE NIPHANOID

PONTOCAINE

Click for Drug Monograph

in liquid-filled capsules, is effective at a dose of 100 to 200 mg po tid. Inhaled ipratropium SOME TRADE NAMES

ATROVENT

Click for Drug Monograph

is not generally considered an antitussive but may be of use in some patients with acute cough due to URI.

Expectorants are thought to decrease viscosity and facilitate expectoration, or coughing up, of secretions, but are of limited benefit.

Guaifenesin SOME TRADE NAMES

ROBITUSSIN

Click for Drug Monograph

(200 to 400 mg po q 4 h in syrup or tablet form) is most commonly used because it has no serious adverse effects, but multiple

expectorants exist, including bromhexine, ipecac, saturated solution of potassium iodide SOME TRADE NAMES

IOSAT

SSKI

THYROSHIELD

Click for Drug Monograph

(SSKI), and domiodol. Aerosolized expectorants, which include isoproterenol SOME TRADE NAMES

ISUPREL

Click for Drug Monograph

, beclomethasone SOME TRADE NAMES

BECLOVENT

BECONASE

Click for Drug Monograph

, N- acetylcysteine SOME TRADE NAMES

MUCOMYST

Click for Drug Monograph

, and deoxyribonuclease (DNase), are generally reserved for hospital-based treatment of cough in patients with bronchiectasis or

cystic fibrosis. Ensuring adequate hydration may facilitate expectoration, as may inhalation of steam, although neither has been

rigorously tested.

Topical treatments, such as acacia, licorice, glycerin, honey, and wild cherry cough drops or syrups (demulcents), are locally and

perhaps emotionally soothing but are not supported by scientific evidence.

 Protussives, which stimulate cough, are indicated for such disorders as cystic fibrosis and bronchiectasis, in which a

productive cough is thought to be important for airway clearance and preservation of pulmonary function. DNase or hypertonic

saline is given in conjunction with chest physical therapy and postural drainage to promote cough and expectoration. This

approach seems to be beneficial in cystic fibrosis but not in most other causes of chronic cough.

A. Approach to the Patient

Communication skills lie at the heart of the physician-patient relationship.

Introduction

Patients go to see their doctors for a variety of reasons, only one of which is to seek relief
from disturbing signs and symptoms of medical disease. As every primary care physician
knows, a large number of patients who visit doctors do not have detectable, much less
serious, underlying disease. Indeed, the most common single diagnosis in general medical
practice is no disease. One explanation for the lack of correlation between the presence of
complaints and visits to physicians lies in the important distinction between disease (the
biologic abnormality) and illness (the persons unique experience of whatever disease he or
she has and the behavior resulting from it). Thus, some patients have little or no disease but
manifest severe illness, and conversely, some patients have severe disease but display little
or no illness. When patients are first seen, however, their physicians do not know the cause of
their complaints and are obliged to look for whatever sickness that may be responsible. This
Section, then, provides some guidelines on how to approach the patient, especially during the
all-important first encounter. Although the emphasis is placed on patients who have
pulmonary disease, the general approach applies to other disorders as well.

Communication

Communication skills lie at the heart of the physician-patient relationship. Doctors must know
how to communicate effectively with patients and their families, including how to deal with the
psychosocial, preventive, and rehabilitative aspects of illnesses. Most physicians, though, are
better at obtaining a medical history and assessing compliance than in learning about
patients understanding of their illnesses, and in ascertaining the patients emotional response
to their disease. Doctors find it easier and are more comfortable with communications related
to the medical aspects of a particular disease than with the psychosocial complications
associated with the same condition. Communication is more than words; it is an interaction of
intellectual and medical give and take that creates an atmosphere whose quality has
enormous impact on the subsequent behavior of the patient. Effective communication
requires calm surroundings, a relaxed environment, and plenty of time, prerequisites that are
not always easy to provide in a busy practitioners office.

Medical History

There is much more to the medical history than asking questions and recording answers,
especially by questionnaire; the expanded concept is reflected in the alternative term, the
face-to-face medical interview, with its verbal and nonverbal nuances. From this interaction,
especially the first one, physicians and patients learn a lot about each other, and this
knowledge has considerable influence on subsequent trust, understanding, concern, and
compliance. Even in the contemporary era of high technology and reliance on laboratory
studies, more diagnoses are made on the basis of a medical history than by any other
method. Of equal importance is the fact that the differential diagnosis derived from the initial
medical history determines which laboratory tests will be ordered.

Present Illness: The three cardinal symptoms of lung disease are dyspnea, cough, and chest
pain; other common manifestations are hemoptysis and wheezing. All are discussed in
subsequent Sections. Regardless of which complaint the patient comes in with, each must be
explored in detail. When did the symptom begin and under what circumstances; when does
the symptom occur now, at night, on awakening, or during exercise? What brought the
symptom on to begin with; moreover, what makes it worse or relieves it now? The time-course
after onset provides important clues to etiology; is the complaint intermittent, progressive, or
evanescent? Also crucial is how the symptom is affecting the patients life style; are daily
activities unrestricted, or are there limitations to going to work, attending school, or shopping
and other household tasks? The intensity of pain needs to be documented; is it bearable or
does it force the sufferer to stop what he or she is doing? Similarly, the severity of
breathlessness should be quantified; how many stairs are manageable or how much exercise
is tolerable? Finally, the consequences of cough should be ascertained; is it productive, and if
so, what is produced; does it wake the patient up at night?

It is equally important to ask questions about associated systemic features, such as fever,
sweats, weight loss, weakness, and fatigue, which are important corollaries of chronic
disease, especially infection and malignancy. No evaluation of pulmonary symptoms is
complete without a detailed history of smoking habits. If the patient says no when asked do
you smoke? the next question must be did you ever smoke? Exposure to cigarettes is
customarily quantified as the number of pack-years, which is calculated by multiplying the
average number of packages of cigarettes smoked daily by the number of years they were
consumed.

Family and Social Histories: Household contact with a family member known to have
tuberculosis or some other respiratory infection may account for similar disease in another
family member. A positive family history provides important clues to the presence of both
common (e.g., asthma) and rare (e.g., hereditary hemorrhagic telangiectasia) pulmonary
diseases. Knowledge of the site(s) of residence helps to diagnose endemic fungal diseases,
and a history of travel suggests possible diseases that may have been encountered in other
countries. It is important to determine if there are risk factors for infection with human
immunodeficiency virus; questions concerning homosexual activity among men and use of
drugs by injection should be asked.

Occupational History: Though often included as part of the social history, the occupational
history is such a key part of the medical history of patients with lung disease that it should be
considered separately. The relationship between the patients complaints and work should be
queried. Has there been exposure to dusts, chemicals, or fumes? Are other workers similarly
afflicted? For completeness, the physician should be concerned about the patients entire
environmental exposure, not just at work. Careful sleuthing about hobbies, recreational
activities, and contact with pets and other animals may furnish solutions to mysterious
medical diseases.

Past History: Many pulmonary diseases tend to recur, especially infections like tuberculosis
and many malignancies. Thus, questions should be asked about previous illnesses,
operations, and trauma involving the chest and/or lungs. One of the most useful aids in
evaluating patients who present with pulmonary symptoms and an abnormal chest x-ray is a
previous chest x-ray. Thus, all patients should be asked about past x-ray examinations, and
every effort should be made to obtain the actual films, not just the reports. Finally, a history of
current and past medications should be obtained with specific identification of any allergies.

Physical Examination

A key element in the initial evaluation of every patient is a complete physical examination.
Subsequent examinations may be more abbreviated as the situation warrants. This Section
emphasizes the detection of signs indicative of pulmonary disease, but finding abnormalities
of other organs is equally important in evaluating patients with different complaints.

Pulmonary Findings: Examination of the lungs still incorporates the basic techniques of
inspection, palpation, percussion, and auscultation. The results of these modalities are
complementary and, as shown in Table 1, allow the examiner to infer the presence and type
of many common pulmonary disorders. Crackles is the new generic term for the
discontinuous sounds that used to be called rales. Moreover, all former descriptors of rales,
such as fine, dry, and wet, have been discarded. The continuous sounds, wheezes and
rhonchi, have also been lumped together in current terminology, but retain some pathogenic
utility: a wheeze is an uninterrupted musical sound that generally originates from narrowing of
medium or small airways, whereas, a rhonchus has a gurgling quality that usually indicates
secretions rattling around within large airways. Other useful signs are a pleural friction rub, a
leathery creaky sound, which is often localized and intensified by pressure with the
stethoscope, and a mediastinal crunch, which sounds like pulmonary crackles (rales), but
which are synchronous with the heart beat and can be heard during breath-holding. A variety
of other sounds may occasionally be heard that originate within the chest wall, such as the
rubbing of hairs underneath the stethoscope, the crackling of subcutaneous emphysema, and
the popping of fractured ribs. It should be emphasized that the absence of physical signs
does not exclude the presence of significant lung disease. A complete evaluation requires a
chest x-ray, and sometimes specialized examinations (e.g., pulmonary function tests or
computed tomography) are needed.

Extrapulmonary Findings: Clubbing of the digits occurs in many different disorders,

including chronic pulmonary infiltrative and suppurative diseases, and most importantly in
bronchogenic carcinoma. Cutaneous lesions are less specific, but may also indicate certain
underlying lung diseases. The examiner should listen to the heart carefully, palpate the
abdomen for enlarged organs or masses, and search the extremities for edema or other
findings. Any abnor-mality on physical examination may be of great help in deciphering the
cause of the patients complaints.

Diagnosis

The diagnosis of no disease can often be confidently made from the medical history alone.
Moreover, when significant disease of the lungs or neighboring structures is present, the
medical history provides important clues as to its origin and what types of studies should be
obtained to confirm its presence or absence. The results of the physical examination
supplement those from the history in deciding which diagnostic tests to order. For suspected
respiratory disease, the first diagnostic test is usually a chest x-ray. For suspected cardiac
disease, the first test is usually an electrocardiogram. From then on, the workup proceeds or
referral is indicated as discussed later in this monograph and in other medical textbooks.

Treatment

Making a diagnosis alone seldom satisfies a sick person. Patients want relief of the complaint
they went to see the physician for in the first place, and that means treatment. Here again, the
distinction between disease and illness must be remembered. The doctor must treat the
underlying disease, for example antibiotics for community-acquired bacterial pneumonia, but
must also attend to the accompanying illness, which might manifest intolerable pleurisy,
nausea and vomiting, or intractable cough. Treatment options should be discussed
thoroughly, and in certain instances, such as before carrying out invasive procedures or
administering toxic drugs, signed consent must be obtained. Because successful treatment,
particularly as an outpatient, requires the patients active cooperation, education and
explanation concerning exactly what must be done is vital; enlisting the support and
collaboration of a family member or friend is helpful.

Medicolegal Concerns

As emphasized in all our previous monographs for primary care physicians, efforts should
constantly be directed toward preventing medical litigation. Patients must be kept informed
about what tests are being ordered and why, what treatment is being recommended, what the
alternatives are, and what plans are being made for follow-up. Perhaps the most frequent
cause of medicolegal awards, ones that concern all patients, not just those with respiratory
disorders, is failure to document adequately in the medical record all contact with, the advice
given to, and the rationale for the approach to a patient and his/her particular problem.
Another common mistake is neglecting to inform the patient, in writing, how to contact the
doctor should the need arise.

Summary

The onset of symptoms, especially those arising in the chest, is one of the chief reasons
patients seek help from their physicians. Evaluation of presenting complaints begins with a
medical interview and is followed by a thorough physical examination. From these
fundamental maneuvers, physicians formulate a clinical impression about what and where the
abnormality is, and if necessary, test this hypothesis by ordering laboratory tests, radiographic
examinations, or other diagnostic procedures. Subsequent evolution of the condition can also
be assessed simply and inexpensively through the medical history and physical examination,
and, when needed, by selected confirmatory test.

ASCITES

n medicine (gastroenterology), ascites (also known as peritoneal cavity fluid,

peritoneal fluid excess, hydroperitoneum or more archaically as abdominal
dropsy) is an accumulation of fluid in the peritoneal cavity. Although most
commonly due to cirrhosis and severe liver disease, its presence can portend other
significant medical problems. Diagnosis of the cause is usually with blood tests, an
ultrasound scan of the abdomen and direct removal of the fluid by needle or
paracentesis (which may also be therapeutic). Treatment may be with medication
(diuretics), paracentesis or other treatments directed at the cause.

Contents

[hide]
1 Signs and symptoms
2 Classification
3 Diagnosis
4 Causes
5 Pathophysiology
6 Treatment
o 6.1 High SAAG
6.1.1 Salt restriction
6.1.2 Diuretics
6.1.3 Water restriction
6.1.4 Paracentesis
6.1.5 Liver transplantation
6.1.6 Shunting
o 6.2 Low SAAG
7 Complications
o 7.1 Spontaneous bacterial peritonitis
8 Cultural significance

9 References

[edit] Signs and symptoms

Mild ascites is hard to notice, but severe ascites leads to abdominal distension.
Patients with ascites generally will complain of progressive abdominal heaviness and
pressure as well as shortness of breath due to mechanical impingement on the
diaphragm.

Ascites is detected on physical examination of the abdomen by visible bulging of the

flanks in the reclining patient ("flank bulging"), "shifting dullness" (difference in
percussion note in the flanks that shifts when the patient is turned on the side) or in
massive ascites with a "fluid thrill" or "fluid wave" (tapping or pushing on one side
will generate a wave-like effect through the fluid that can be felt in the opposite side
of the abdomen).

Other signs of ascites may be present due to its underlying etiology. For instance, in
portal hypertension (perhaps due to cirrhosis or fibrosis of the liver) patients may also
complain of leg swelling, bruising, gynecomastia, hematemesis, or mental changes
due to encephalopathy. Those with ascites due to cancer (peritoneal carcinomatosis)
may complain of chronic fatigue or weight loss. Those with ascites due to heart failure
may also complain of shortness of breath as well as wheezing and exercise
intolerance.

[edit] Classification

Ascites exists in three grades:[1]

Grade 1: mild, only visible on ultrasound

Grade 2: detectable with flank bulging and shifting dullness
Grade 3: directly visible, confirmed with fluid thrill

[edit] Diagnosis

Routine complete blood count (CBC), basic metabolic profile, liver enzymes, and
coagulation should be performed. Most experts recommend a diagnostic paracentesis
be performed if the ascites is new or if the patient with ascites is being admitted to the
hospital. The fluid is then reviewed for its gross appearance, protein level, albumin,
and cell counts (red and white). Additional tests will be performed if indicated such as
Gram stain and cytology.[2]

The Serum-ascites albumin gradient (SAAG) is probably a better discriminant than

older measures (transudate versus exudate) for the causes of ascites.[3] A high gradient
(> 1.1 g/dL) indicates the ascites is due to portal hypertension. A low gradient (< 1.1
g/dL) indicates ascites of non-portal hypertensive etiology.

Ultrasound investigation is often performed prior to attempts to remove fluid from the
abdomen. This may reveal the size and shape of the abdominal organs, and Doppler
studies may show the direction of flow in the portal vein, as well as detecting Budd-
Chiari syndrome and portal vein thrombosis. Additionally, the sonographer can make
an estimation of the amount of ascitic fluid, and difficult-to-drain ascites may be
drained under ultrasound guidance. Abdominal CT scan is a more accurate alternate to
reveal abdominal organ structure and morphology.
[edit] Causes

Causes of high SAAG ("transudate") are:[2]

Cirrhosis - 81% (alcoholic in 65%, viral in 10%, cryptogenic in 6%)

Heart failure - 3%
Budd-Chiari syndrome or veno-occlusive disease
Constrictive pericarditis
Kwashiorkor

Causes of low SAAG ("exudate") are:

Cancer (primary peritoneal carcinomatosis and metastasis) - 10%

Tuberculosis - 2%

Pancreatitis - 1%

Serositis

Nephrotic syndrome

Hereditary angioedema[4]

[edit] Pathophysiology

Ascitic fluid can accumulate as a transudate or an exudate. Amounts of up to 25 liters

are fully possible.

Roughly, transudates are a result of increased pressure in the portal vein (>8 mmHg,
usually around 20 mmHg[5]), e.g. due to cirrhosis, while exudates are actively secreted
fluid due to inflammation or malignancy. As a result, exudates are high in protein,
high in lactate dehydrogenase, have a low pH (<7.30), a low glucose level, and more
white blood cells. Transudates have low protein (<30g/L), low LDH, high pH, normal
glucose, and fewer than 1 white cell per 1000 mm. Clinically, the most useful
measure is the difference between ascitic and serum albumin concentrations. A
difference of less than 1 g/dl (10 g/L) implies an exudate.[2]

Portal hypertension plays an important role in the production of ascites by raising

capillary hydrostatic pressure within the splanchnic bed.

Regardless of the cause, sequestration of fluid within the abdomen leads to additional
fluid retention by the kidneys due to stimulatory effect on blood pressure hormones,
notably aldosterone. The sympathetic nervous system is also activated, and renin
production is increased due to decreased perfusion of the kidney. Extreme disruption
of the renal blood flow can lead to the feared hepatorenal syndrome. Other
complications of ascites include spontaneous bacterial peritonitis (SBP), due to
decreased antibacterial factors in the ascitic fluid such as complement.

[edit] Treatment

Ascites is generally treated simultaneously while an underlying etiology is sought in

order to prevent complications, to relieve symptoms and to prevent further
progression. In patients with mild ascites, therapy is usually as an outpatient. The goal
is weight loss of no more than 1.0 kg/day for patients with both ascites and peripheral
edema and no more than 0.5 kg/day for patients with ascites alone.[6] In those with
severe ascites causing a tense abdomen, hospitalization is generally necessary for
paracentesis.[7][8]

[edit] High SAAG

[edit] Salt restriction

Salt restriction is the initial treatment, which allows diuresis (production of urine)
since the patient now has more fluid than salt concentration. Salt restriction is
effective in about 15% of patients.[9]

[edit] Diuretics

Since salt restriction is the basic concept in treatment, and aldosterone is one of the
hormones that acts to increase salt retention, a medication that counteracts aldosterone
should be sought. Spironolactone (or other distal-tubule diuretics such as triamterene
or amiloride) is the drug of choice since they block the aldosterone receptor in the
collecting tubule. This choice has been confirmed in a randomized controlled trial.[10]
Diuretics for ascites should be dosed once per day.[11] Generally, the starting dose is
oral spironolactone 100 mg/day (max 400 mg/day). 40% of patients will respond to
spironolactone.[9] For nonresponders, a loop diuretic may also be added and generally,
furosemide is added at a dose of 40 mg/day (max 160 mg/day), or alternatively
(bumetanide or torasemide). The ratio of 100:40 reduces risks of potassium
imbalance.[11] Serum potassium level and renal function should be monitored closely
while on these medications.[12]

Monitoring diuresis: Diuresis can be monitored by weighing the patient daily. The
goal is weight loss of no more than 1.0 kg/day for patients with both ascites and
peripheral edema and no more than 0.5 kg/day for patients with ascites alone.[6] If
daily weights cannot be obtained, diuretics can also be guided by the urinary sodium
concentration. Dosage is increased until a negative sodium balance occurs.[11] A
random urine sodium-to-potassium ratio of > 1 is 90% sensitivity in predicting
negative balance (> 78-mmol/day sodium excretion).[13]

Diuretic resistance: Diuretic resistance can be predicted by giving 80 mg intravenous

furosemide after 3 days without diuretics and on an 80 mEq sodium/day diet. The
urinary sodium excretion over 8 hours < 50 mEq/8 hours predicts resistance.[14]

If a patient exhibits a resistance to or poor response to diuretic therapy, ultrafiltration

or aquapheresis may be needed to achieve adequate control of fluid retention and
congestion. The use of such mechanical methods of fluid removal can produce
meaningful clinical benefits in patients with diuretic resistance and may restore
responsiveness to conventional doses of diuretics.[15][16]

[edit] Water restriction

Water restriction is needed if hyponatremia < 130 mmol per liter develops.[12]
[edit] Paracentesis
Main article: Paracentesis

In those with severe (tense) ascites, therapeutic paracentesis may be needed in

addition to medical treatments listed above.[7][8] As this may deplete serum albumin
levels in the blood, albumin is generally administered intravenously in proportion to
the amount of ascites removed.

[edit] Liver transplantation

Main article: liver transplantation

Ascites that is refractory to medical therapy is considered an indication for liver

transplantation. In the United States, the MELD score (online calculator)[17] is used to
prioritize patients for transplantation.

[edit] Shunting

In a minority of patients with advanced cirrhosis that have recurrent ascites, shunts
may be used. Typical shunts used are portacaval shunt, peritoneovenous shunt, and the
transjugular intrahepatic portosystemic shunt (TIPS). However, none of these shunts
has been shown to extend life expectancy, and are considered to be bridges to liver
transplantation. A meta-analysis of randomized controlled trials by the international
Cochrane Collaboration concluded that "TIPS was more effective at removing ascites
as compared with paracentesis...however, TIPS patients develop hepatic
encephalopathy significantly more often"[18]

[edit] Low SAAG

Exudative ascites generally does not respond to manipulation of the salt balance or
diuretic therapy. Repeated paracentesis and treatment of the underlying cause is the
mainstay of treatment.

[edit] Complications

[edit] Spontaneous bacterial peritonitis

Main article: Spontaneous bacterial peritonitis

[edit] Cultural significance

It has been suggested that ascites was seen as a punishment especially for oath-
breakers among the Proto-Indo-Europeans.[19] This proposal builds on the Hittite
military oath as well as various Vedic hymns (RV 7.89, AVS 4.16.7). A similar curse
dates to the Kassite dynasty (12th century BC), threatening oath-breakers: "May
Marduk, king of heaven and earth, fill his body with dropsy, which has a grip that can
never be loosened".[citation needed] Comparable is also